Provider Demographics
NPI:1053743153
Name:FIRST IMPRESSIONS DENTISTRY
Entity type:Organization
Organization Name:FIRST IMPRESSIONS DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-879-0000
Mailing Address - Street 1:4301 NW 63RD ST
Mailing Address - Street 2:300
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-1549
Mailing Address - Country:US
Mailing Address - Phone:405-879-0000
Mailing Address - Fax:405-879-0656
Practice Address - Street 1:4301 NW 63RD ST
Practice Address - Street 2:300
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-1549
Practice Address - Country:US
Practice Address - Phone:405-879-0000
Practice Address - Fax:405-879-0656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-31
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK60611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200231440 AMedicaid